(must have an existing checking account with Penn Liberty Bank to enroll)

Today's Date*

Select your Branch Location

Upgrade from Basic Service (Relationship or Classis Club members)Last four digits of checking account #

New Enrollment Last four digits of checking account #

Customer Information:

*Name:

*Street Address

*City

*State

*Zip

*Phone

Email

By pressing the “Submit” button below you acknowledge:

I understand that the cost to enroll in the Premier Service provided by ID Theft Asisst is $7.00 per month and that this charge will be deducted automatically each month from my checking account indicated above.

I understand that I will be contacted by a Penn Liberty Banker to confirm my enrollment, determine the effective date of my coverage, and arrange for me to receive my welcome letter with a subscriber ID card.

I may cancel coverage at any time by contacting any branch office of Penn Liberty Bank.